Objective: Transient choreatic movements are known as side effects of DBS of the dorsolateral STN in Parkinson disease (PD). Persistent “brittle” dyskinesia have been reported in PD patients after STN DBS in STIM ON-State, however, they disappear in STIM OFF-state (Sriam 2014). Persistent dyskinetic movements in STIM OFF-state have been described in anteromedial STN-DBS in patients with obsessive compulsive disorder (Mulders 2017). We here describe a patient with persistent left shoulder dyskinesia after bilateral deep brain stimulation (DBS) in the dorsolateral subthalamic nucleus (STN) in medication OFF-state when the stimulation was turned off.

Background: In 2015 our then 71year old female patient received STN-DBS for advanced Parkinson’s Disease (PD). Post-operative CT-Scan showed no bleeding and correct electrode position. Shortly after the operation, dyskinesia of the left shoulder occurred, worsened by increasing dopaminergic drug dose, but partly improved by adaptation of the stimulation parameters. However, the improvement was only temporary, lasting for several hours to days before dyskinesia reoccurred. An elaborated drug regime to reduce dyskinesia including dopamine agonist, amantadine and safinamide showed only moderate effect. The patient was disturbed by the dyskinesia in her quality of life, as they became more painful and led to orthopedic problems of the left shoulder.

Methods: To thoroughly examine these dyskinetic unilateral shoulder movements we hospitalized the patient in October 2017 and evaluated motor symptoms using MDS-UPDRS III after drug withdrawal (MED OFF) and stimulation turned off (STIM OFF).

Results: In MED OFF and STIM OFF state the patient continued to have choreatic movements of the left shoulder. We compared our findings to the video sequence of the preoperative examination in MED OFF-state and noticed that the patient did not have these choreatic shoulder movements at that time. After thorough examination, evaluation and adaptation of the stimulation parameters the dyskinetic movements disappeared temporarily over 5 days after stimulation was turned on with very little dopaminergic medication (L-DOPA equivalent daily dose: 230mg/d) and then gradually reappeared and finally returned to the same intensity as before.

Conclusions: To our knowledge, this is the first report of post-operative occurrence of persistent dyskinesia in dorsolateral STN-DBS in OFF-state. We suspect a post-operative structural change of the STN not detectable with CT-Scan.

References: – Sriram A, Foote KD, Oyama G, Kwak J, Zeilman PR, Okun MS. Brittle Dyskinesia Following STN but not GPi Deep Brain Stimulation.Tremor Other Hyperkinet Mov (N Y). 2014 Jun 5;4:242. – Mulders AEP, Leentjens AFG, Schruers K, Duits A, Ackermans L, Temel Y. Choreatic Side Effects of Deep Brain Stimulation of the Anteromedial Subthalamic Nucleus for Treatment-Resistant Obsessive-Compulsive disorder. World Neurosurg. 2017 Aug;104:1048.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/stn-dbs-causing-persistent-dyskinetic-movements-in-off-state/